I am no expert in chest tubes, and will add the caveat that for this particular post I really hope everything is correct! If it’s not, let me know! See this post on the different kinds of chest tubes. This is a great but long nursing resource from RN.com.
You’ve placed a chest tube: great! Now you hook it up to some weird box thing that is called a drainage system…now what? Knowing how chest tubes used to work helps you understand the box thing.
This picture is taken from a truly excellent little video on how chest tube drainage works:
There used to be 3 separate bottles hooked up to the chest tube itself: Bottle #1 is where the patient’s empyema fluid or blood leaked into. Bottle #2 is the waterseal: air is forced to travel through water and can only move in one direction (it cannot move back into the patient). Bottle #3 sets suction power based on how much water is in the bottle–more water=less suction, less water=more suction, and you need to make sure the suction power is just right. You can see how the drainage system has evolved over time on the right.
Should patients be “placed to waterseal” or “placed to -20 suction?”
“Place to waterseal”= don’t be too crazy with drainage, which is appropriate for most pleural effusions or a mild pneumothorax. If the lung is not fully expanded, you can “turn up the suction.”If you apply suction too aggressively, you put the patient at risk for re-expansion pulmonary edema.
How do I know if there is an “air leak” and what the heck does it mean?
An air leak is present if there is bubbling in the waterseal chamber when the suction is clamped/on waterseal–this indicates there is still air flowing from the chest to the tube. Positive pressure coming from the pleural space=air getting into the pleural space. Intermittent bubbling with expiration (when pleural pressure is highest in the non-ventilated patient) may be normal, but a continuous air leak is pathological and means the patient is not ready to have their chest tube pulled!
You can “clamp” the tubing, which should stop an air leak. If the air leak persists even with clamping, consider:
- ruptured bleb (severe emphysema)
- simple traumatic pneumothorax (from placing the chest tube)
- a leak in the actual tubing system
- mechanical ventilation (may see decreased tidal volumes, failure of PEEP increase)
- bronchopleural fistula (usually more severe or continuous)
- lung entrapment vs. trapped lung
NB: if your patient has a persistent air leak, think twice about pulling their chest tube because if you do, you may cause a recurrent pneumothorax.
What is “tidaling?”
You may see movement in the waterseal chamber with respiratory variation. It’s the water being sucked back towards the lung with inspiration due to negative inspiratory pressure. (In mechanically ventilated patients, it’s the opposite.)
How do I know when the tube can be taken out?
In a 2013 study out of Michigan State, the team found it is reasonable to remove chest tubes when drainage <200 ml/day, on waterseal, with no air leak. In stable patients on the floor, theoretically you don’t need a chest x-ray after removal, but given our litigious society, everyone gets one. In mechanically ventilated patients, you should get a chest x-ray 1-3 hours after removal. However there is no need for regular surveillance chest imaging while a patient has a chest tube in.
What do I do if the tube falls out?
Use common sense: cover the area and prepare to re-insert a chest tube. Maintain sterility. The patient is at risk of a tension pneumothorax, so someone should stay with them for close monitoring. More troubleshooting at this nursing website.